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DSM 5 ASD and other Neurodevelopmental Disorders Janine M. Montgomery, PhD Manitoba Association of School Psychologists SAGE event University of Manitoba October 25, 2013

*DSM and DSM-5 are registered trademarks of the American Psychiatric Association. The American Psychiatric Association is not affiliated with nor endorses this seminar.

Disclosure

*DSM and DSM-5 are registered trademarks of the American Psychiatric Association. The American Psychiatric Association is not affiliated with nor endorses this seminar. •  Limits to expertise

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http://forensicpsychologist.blogspot.ca/2010_08_01_archive.html

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Agenda 1.  Brief Overview of Broad Changes in DSM 5 2.  Specific Categories

•  ASD: What’s all the fuss about? •  IDD •  AD/HD •  SLD

3. Implications? •  Practical implications •  Research?

Primary Source material for this presentation: American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013

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DSM 5

“a living document with a permanent revision infrastructure to enable revision of specific diagnostic areas in which new evidence is replicated and reviewed as ready for adoption” (Regier, Narrow, Kuhl, & Kupfer, 2009).

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Why the revisions? 1.  Lack of clear separation between disorders 2.  Excessive co-morbidities 3.  Over-reliance on NOS 4.  Hierarchal Dx (if ASD, then no AD/HD) 5.  Poor integration of categorical and dimensional

assessment criteria 6.  Developmental considerations 7.  Expression across cultures 8.  Gender

Source: Tannock, R. (2013). Rethinking AD/HD and LD: Proposed changes in diagnostic criteria. Journal of Learning Disabilities 46(5).pp. 6-25. DOI: 10.1177/0022219412464341

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DSM 5: Guiding Framework 1. Designed to be an evidence based tool to guide clinical assessment and Dx

•  Changes should balance science with clinical utility

2. Avoid unnecessary changes 3. Criteria remains behavioral, as the science on diagnostic markers/etiological factors is developing (though potentials are described in text, and often in specifiers) 4. Do no harm

Source: Tannock, R. (2013). Rethinking AD/HD and LD: Proposed changes in diagnostic criteria. Journal of Learning Disabilities 46(5).pp. 6-25. DOI: 10.1177/0022219412464341

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What’s New in DSM 5? • Meta structure:

•  Dimensional approach integrated (preliminary) •  Axial system replaced •  Clusters ‘suggested’ by evidence •  Order of conditions proceeds by development •  Lumpers vs splitters

Dimensions may include continuous assessment of core symptoms, dimensional assessments that cut across different disorders, and spectrum constructs

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DSM 5 Field Trials •  Test to reliability, clinical application, and feasibility •  Test sensitivity to change •  Test cross-cutting measures • Sites

•  Academic/clinical

• Not all conditions participated

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Use of Manual •  To develop a clinical case formation • Definition of mental disorder • Elements of Diagnosis •  The future

•  Recommended assessment monitoring/tools

• While the DSM was/is meant to draw from research, particularly stats and etiological factors, research is not there yet. •  Guidance relating to research on these matters, when known are

provided in text.

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Diagnostic Specifiers in General • Differ, dependent on category • Not mutually exclusive or jointly exhaustive • Essentially, you diagnose the general disorder, then

specify the characteristics which may apply to: •  Symptom Threshold •  Age of Onset •  Pervasiveness of symptoms across settings •  With or without known features for the group •  Specifying the impact and characteristics “at the present time” •  Associated with known condition (Neuropsych, medical, or

neurodevelopmental disorder)

• Specify CURRENT FUNCTIONING

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Diagnostic Specifiers in General Mention: • Culturally relevant information • Gender specific •  If meets full criteria, then

•  Severity •  Mild, Moderate, Severe, Extreme/Profound

•  Descriptive: Insight •  Course (e.g. remission)

•  If they do not meet full criteria, code as: •  Other specified disorder

•  Reason criteria not met •  Unspecified disorder

•  No reason required

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Diagnostic Considerations

• Must consider exclusions • Distress or impairment must exist

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Neurodevelopmental Disorders

Denotes those directly covered today

DSM 5

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General Info on Neurodevelopmental Disorders

•  Communication Disorders - Restructured to now include Social Communication Disorder plus two diagnostic categories: Language Disorders and Speech Disorders. •  These categories each contain appropriate subtypes to cover all seven of the

disorders previously proposed for this diagnostic category (Language Emergence; Specific Language Impairment; Social Communication Disorder; Voice Disorder; Speech-Sound Disorder; Motor Speech Disorder; Child Onset Fluency Disorder).

•  Learning Disorder has been changed to Specific Learning Disorder and the previous types of Learning Disorder (Dyslexia, Dyscalculia, and Disorder of Written Expression) are no longer being recommended. The type of Learning Disorder will instead be specified as noted in the diagnosis.

•  Social Communication Disorder has undergone some moderate wording changes for consistency with wording of other DSM-5 Neurodevelopmental Disorders

•  Attention-Deficit/Hyperactivity Disorder - minor wording changes •  Chronic Tic Disorder, Tic Disorder Not Elsewhere Classified, and Tic Disorder

Associated With Another Medical Condition - minor wording changes •  Addition of criteria for Attention-Deficit/Hyperactivity Disorder Not Elsewhere

Classified

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Dx Criteria for Neurodevelopmental disorders: General Approach

A.  Key Characteristics B.  Measurement of Key Characteristics C.  Age at Onset D.  Exclusionary Criteria

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Other and Unspecified

Other Specified ND

• Subthreshold presentations of any ND, that cause significant impairment.

• Used when a clinician records a reason for not meeting criteria

Unspecified ND

• Subthreshold presentations of any ND, that causes significant impairment

• Used when clinician choses not to specify why the individual does not meet criteria, including insufficient information

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Determining Level of Support • Cautions:

• No defined process for determining • Co-morbid issues may influence interpretation • Variations in cognitive/adaptive needs may make this

tricky • Use of these may change with research • How to quantify support?

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Why the drastic changes to Autism Spectrum?

• Poor reliability across sites/practitioners • No consensus on differences between subtypes

•  See Tsai, 2013; Tsai and Ghazzudiun, 2013 for rebuttal

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AUTISM SPECTRUM DISORDERS

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Autism Spectrum Disorder A.  Persistent deficits in social communication and social

interaction across multiple contexts, as manifested by the following*:

1.  Deficits in Social-emotional reciprocity 2.  Deficits in Nonverbal communication 3.  Deficits in developing/maintaining relationships

B.  Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following*:

1.  Stereotyped or repetitive speech, motor movements, or use of objects 2.  Excessive adherence to routines, ritualized patterns of verbal or

nonverbal behavior, or excessive resistance to change 3.  Highly restricted, fixated interests that are abnormal in intensity and

focus 4.  Hyper- or Hypo- reactivity to sensory input or unusual sensory aspects

of environment

*Currently or by history

All of these

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A. Social/Communication 1.  Deficits in Social-emotional reciprocity ranging from, for example:

a.  abnormal social approach and failure of normal back-and-forth conversation

b.  reduced sharing of interests, emotions, or affect; c.  failure to initiate or respond to social interactions.

2.  Deficits in Nonverbal communication ranging from: a.  poorly integrated verbal and nonverbal communication; b.  to abnormalities in eye contact and body language c.  or deficits in understanding and use of gestures; to a total lack

of facial expressions and nonverbal communication.

3.  Deficits in developing, maintaining, and understanding relationships, ranging, for example

a.  difficulties adjusting behavior to suit various social contexts b.  difficulties in sharing imaginative play or in making friends c.  absence of interest in peers.

Requires at least one from each area

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B. Repetitive/Restricted Behaviors & Interests

1.  Stereotyped or repetitive motor movements, use of objects, or speech ranging from: q  simple motor stereotypies, q  lining up toys or flipping objects, q  echolalia, q  idiosyncratic phrases.

2.  Insistence on sameness, inflexible adherence to routines, or ritualized patterns or verbal nonverbal behavior ranging from:

q  extreme distress at small changes q  difficulties with transitions q  rigid thinking patterns, q  greeting rituals, q  need to take same route or eat same food every day

3.  Highly restricted, fixated interests that are abnormal in intensity or focus q  strong attachment to or preoccupation with unusual objects q  excessively circumscribed or perseverative interest (s)

4.  Hyper- or hypo-reactivity to sensory input or unusual interests in sensory aspects of the environment

q  apparent indifference to pain/temperature q  adverse response to specific sounds or textures q  excessive smelling or touching of objects q  visual fascination with lights or movement

NEW!

* Only 2 are needed to meet criteria

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ASD continued… C. Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life). D. Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning. E. These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay. Intellectual disability and autism spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spectrum disorder and intellectual disability, social communication should be below that expected for general developmental level.

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Specifiers q  With/without accompanying intellectual disorder q  With/without accompanying language disorder q  Associated with known medical/genetic or environmental factor

q  epilepsy, sleep problems, and constipation, avoidant-restrictive food intake disorder

q  Associated with another neurodevelopmental disorder q  With catatonia

See Lai et al., 2013 Subgrouping the Autism ‘‘Spectrum’’: Reflections on DSM-5 (available free online) for a list of potential specifiers.

Individuals with a well-established DSM-IV diagnosis of autistic disorder, Asperger’s disorder, or pervasive developmental disorder not otherwise specified should be given the diagnosis of autism spectrum disorder. Individuals who have marked deficits in social communication, but whose symptoms do not otherwise meet criteria for autism spectrum disorder, should be evaluated for social (pragmatic) communication disorder.

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ASD Severity Levels

Source: APA 2013, DSM 5

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Associated features •  Language and/or intellectual deficits • Motor deficits • Self-injury • Adolescents/adults prone to anxiety/depression • Catatonic-like motor behaviour • Cultural and Gender considerations • An absence of developmental information does not rule

out ASD

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Conditions to consider with ASD Mental and Neurodevelopmental

Disorders

•  IDD •  Language Impairment •  AD/HD •  Depressive and bi-polar

disorders •  Anxiety Disorders •  Motor, sensory and other

disorders •  SLD •  Developmental co-ordination

disorder

Differential Dx

• Rett Syndrome • Selective Mutism • Communication

Disorders/Language impairment/social pragmatic disorder

•  IDD • Stereotypic movement

disorder • Schizophrenia

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So, How research based is the criteria? Authors Sensitivity Specificity

AuD AS PDD-NOS

McPartland et al. 2013 75.8% 25% 28.3% 94.9%

Huerta, 2012 .53 .24% Tsai, 2012 Frazier et al., 2012 81% 97% Worley, 2012 32 % decrease in Dx cases from DSM IV to 5. Matson 47.9% fewer toddlers Dx from DSM IV to 5 Gibbs et al. 23.4 % decrease in Dx cases from DSM IV to 5.

Regier et al, 2013 DSM 5 Field trials reliability

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SOCIAL (PRAGMATIC) COMMUNICATION DISORDER

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Social (Pragmatic) Communication Disorder

A.  Persistent difficulties in the social use of verbal and nonverbal communication as manifested by all of the following:

1.  Deficits in using communication for social purposes, such as: •  greeting and sharing information, in a manner that is appropriate for

the social context. 2.  Impairment of the ability to change communication to match context

or the needs of the listener, such as •  speaking differently in a classroom than on a playground, talking

differently to a child than to an adult, and avoiding use of overly formal language.

3.  Difficulties following rules for conversation and storytelling, such as •  taking turns in conversation, rephrasing when misunderstood, and

knowing how to use verbal and nonverbal signals to regulate interaction.

4.  Difficulties understanding what is not explicitly stated (e.g., making inferences) and nonliteral or ambiguous meanings of language •  idioms, humor, metaphors, multiple meanings that depend on the

context for interpretation.

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SPCD continued…. B.  The deficits result in functional limitations in effective

communication, social participation, social relationships, academic achievement, or occupational performance, individually or in combination

C.  The onset of the symptoms is in the early developmental period (but deficits may not become fully manifest until social communication demands exceed limited capacities).

D.  The symptoms are not attributable to another medical or neurological condition or to low abilities in the domains of word structure and grammar, and are not better explained by autism spectrum disorder, intellectual disability (intellectual developmental disorder), global developmental delay, or another mental disorder.

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Associated features of SPCD •  Language impairment

•  “characterized by a history of delay in reaching language milestones, and historical, if not current, structural language problems”

• Attention-deficit/hyperactivity disorder (AD/HD), behavioral problems, and specific learning disorders are also more common in this group

•  Family history of autism spectrum disorder, communication disorders, or specific learning disorder appears to increase the risk

How does this

apply to AS?

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Conditions to consider with SPCD Mental and Neurodevelopmental

Disorders

•  Language Impairment • AD/HD • SLD

Differential Dx

• ASD • AD/HD • Social Anxiety(social

phobia) •  IDD • SLD

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INTELLECTUAL (DEVELOPMENTAL)

DISABILITY

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Intellectual (Developmental) Disability Changes:

• Category Name • Developmental period (vs. age) •  Increased emphasis on adaptive functioning • Severity by adaptive functioning, not IQ

Notes:

• Synonymous with proposed ICD-11 • No current field trials for this condition

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Intellectual (Developmental) Disability • Deficits in:

A.  Intellectual B.  Adaptive functioning

•  in comparison to an individual’s age-, gender-, and socioculturally matched peers

C.  Onset in ‘developmental period’

• Severity is coded according to adaptive skills •  Mild, Moderate, Severe, Profound •  Conceptual, Social, Practical Domains

“The diagnosis of intellectual disability is based on both clinical assessment and standardized testing of intellectual and adaptive functions”.

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IDD Criteria The following three criteria must be met: A.  Deficits in intellectual functions, such as:

•  reasoning, problem solving, planning, abstract thinking, judgment, academic learning, and learning from experience

•  confirmed by both clinical assessment and individualized, standardized intelligence testing.

B.  Deficits in adaptive functioning that result in failure to meet developmental and sociocultural standards for personal independence and social responsibility.

•  Without ongoing support, the adaptive deficits limit functioning in one or more activities of daily life, such as: •  communication, social participation, and independent living, across multiple

environments, such as home, school, work, and community. •  Adaptive deficits should be related to intellectual deficits (If not, consider

another Dx)

C. Onset of deficits during the developmental period.

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Intellectual Functioning Guidelines: • Scores of approximately two standard deviations or

more below the population mean •  including a margin for measurement error (generally +5 points). On

tests with a standard deviation of 15 and a mean of 100, this involves a score of 65–75 (70 ± 5).

• Co-occurring disorders that affect communication, language, and/or motor or sensory function may affect test scores.

• Clinical training and judgment are required to interpret test results and assess intellectual performance. “a person with an IQ score above 70 may have such severe adaptive behavior problems in social judgment, social understanding, and other areas of adaptive functioning that the person’s actual functioning is comparable to that of individuals with a lower IQ score”

http://dsm.psychiatryonline.org.proxy2.lib.umanitoba.ca/content.aspx?bookid=556&sectionid=41101757#103436419, October 12, 2013.

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IDD Specifiers: Severity Levels See handout for details: • Severity:

•  defined on the basis of adaptive functioning, and not IQ scores, to reflect supports required

•  IQ measures are less valid in the lower end of the IQ range.

Severity  level   Conceptual  domain   Social  domain   Practical  domain  

Mild Moderate Severe Profound

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Additional Considerations for IDD Assessment

• Suicide Risk: Individuals with co-existing conditions have elevated risk

• Gullibility: May be an important consideration to document, particularly if Justice is involved.

• Poor communication skills: may predispose to disruptive and aggressive behaviors

• Genetic disorders: may require medical or physical treatments or other medical monitoring and may involve regression. •  If you suspect, please refer.

Screen for

suicide risk

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Other Tips for IDD assessment •  When choosing parent informants, ensure their cognition renders

them capable of accurate completion of any forms •  “When intellectual disability results from a loss of previously acquired

cognitive skills, as in severe traumatic brain injury, the diagnoses of intellectual disability and of a neurocognitive disorder may both be assigned”.

http://dsm.psychiatryonline.org.proxy2.lib.umanitoba.ca/content.aspx?bookid=556&sectionid=41101757#103436419, October 12, 2013.

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Ongoing monitoring for IDD •  “In some cases, these result in significant improvement of

intellectual functioning, such that the diagnosis of intellectual disability is no longer appropriate.”

•  “Diagnostic assessments must determine whether improved adaptive skills are: •  the result of a stable, generalized new skill acquisition (in which

case the diagnosis of intellectual disability may no longer be appropriate)

or •  whether the improvement is contingent on the presence of supports

and ongoing interventions (in which case the diagnosis of intellectual disability may still be appropriate)”.

Retrieved from: http://dsm.psychiatryonline.org.proxy2.lib.umanitoba.ca/content.aspx?bookid=556&sectionid=41101757#103436419, October 12, 2013.

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Conditions to consider with IDD Mental and Neurodevelopmental

Disorders

• AD/HD • Depressive and bi-polar

disorders • Anxiety Disorders, •  ASD • Motor, sensory and other

disorders

Differential Dx

• Major and Mild Neurocognitive disorders

• Communication Disorders/Language impairment

• ASD

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Additional Categories related to Intellectual (Developmental) Disability

• Global Developmental Delay •  < 5 years •  Several Areas of Delay, including several areas of cognition •  Unable to undergo systematic assessment (tentative Dx)

• Unspecified Intellectual Disability •  > 5 years •  Unable to assess because of sensory issues (hearing/vision),

locomotor disability, or presence of co-occurring disorders •  Use only in exceptional circumstances; necessitates re-

assessment with time.

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ATTENTION DEFICIT HYPERACTIVITY DISORDER

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AD/HD: Changes to criteria • Examples added to facilitate life span applications • Cross-situational requirement strengthened to:

•  “several” symptoms in each setting • Onset criterion: changed from:

•  “symptoms that caused impairment were present before age 7 years” •  “several inattentive or hyperactive-impulsive symptoms were present

prior to age 12” • Subtypes have been replaced with presentation specifiers

that map directly to the prior subtypes • Co-morbid autism spectrum disorder is now allowed • Symptom threshold for adults.

•  only need to meet five symptoms in either of the two major domains: inattention and hyperactivity/impulsivity

Source: http://pro.psychcentral.com/2013/dsm-5-changes-attention-deficit-hyperactivity-disorder-AD/HD/004321.html

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AD/HD (Inattention) Criteria A. A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, as characterized by (1) and/or (2): 1. Inattention: 6 (or more) symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities:

a.  Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (e.g., overlooks or misses details, work is inaccurate).

b.  Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations, or lengthy reading).

c.  Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction).

d.  Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., starts tasks but quickly loses focus and is easily sidetracked).

e.  Often has difficulty organizing tasks and activities (e.g., difficulty managing sequential tasks; difficulty keeping materials and belongings in order; messy, disorganized work; has poor time management; fails to meet deadlines).

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AD/HD (Inattention) Criteria, cont…. f.  Often avoids, dislikes, or is reluctant to engage in tasks that require sustained

mental effort (e.g., schoolwork or homework; for older adolescents and adults, preparing reports, completing forms, reviewing lengthy papers).

g.  Often loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).

h.  Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts).

i.  Is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents and adults, returning calls, paying bills, keeping appointments).

Note: The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or failure to understand tasks or instructions. For older adolescents and adults (age 17 and older), at least five symptoms are required.

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AD/HD Hyperactive/Impulsive Criteria 2. Hyperactivity and impulsivity: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities: a.  Often fidgets with or taps hands or feet or squirms in seat. b.  Often leaves seat in situations when remaining seated is expected (e.g., leaves his

or her place in the classroom, in the office or other workplace, or in other situations that require remaining in place).

c.  Often runs about or climbs in situations where it is inappropriate. (Note: In adolescents or adults, may be limited to feeling restless.)

d.  Often unable to play or engage in leisure activities quietly. e.  Is often “on the go,” acting as if “driven by a motor” (e.g., is unable to be or

uncomfortable being still for extended time, as in restaurants, meetings; may be experienced by others as being restless or difficult to keep up with).

f.  Often talks excessively. g.  Often blurts out an answer before a question has been completed (e.g., completes

people’s sentences; cannot wait for turn in conversation). h.  Often has difficulty waiting his or her turn (e.g., while waiting in line). i.  Often interrupts or intrudes on others (e.g., butts into conversations, games, or

activities; may start using other people’s things without asking or receiving permission; for adolescents and adults, may intrude into or take over what others are doing)

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Criteria for AD/HD….cont. B.  Several inattentive or hyperactive-impulsive symptoms were

present prior to age 12 years. C.  Several inattentive or hyperactive-impulsive symptoms are

present in two or more settings (e.g., at home, school, or work; with friends or relatives; in other activities).

D.  There is clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, or occupational functioning.

E.  The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better explained by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication or withdrawal).

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AD/HD Specifiers Presentations • Hyperactive/Impulsive (≥ 6 hyp/imp, but ≤ 5 inattention) •  Inattentive (≥ 6 inattention, but ≤ 5 hyp/imp) • Combined (≥ 6 inattention AND ≥ 6 hyp/imp) • Partial Remission(≤ 6 inattention, ≤ 6 hyp/imp, but had a

Dx in past and remains impaired)

Source: Tannock,R. (2012). Rethinking ADHD and LD in DSM-5 Proposed Changes in Diagnostic Criteria. Journal of Learning Disabilities. 46 (6), 1-26.

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AD/HD Severity Specifiers • Mild: Few, if any, symptoms in excess of those required to

make the diagnosis are present, and symptoms result in no more than minor impairments in social or occupational functioning.

• Moderate: Symptoms or functional impairment between “mild” and “severe” are present.

• Severe: Many symptoms in excess of those required to make the diagnosis, or several symptoms that are particularly severe, are present, or the symptoms result in marked impairment in social or occupational functioning.

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Conditions to consider with AD/HD Mental and Neurodevelopmental

Disorders

•  LD •  Conduct Disorder •  Disruptive mood

Dysregulation disorder •  Anxiety •  Depression •  Intermittent Explosive

Disorder •  Substance Abuse •  OCD •  Tic Disorders •  ASD

Differential Dx

•  ODD •  Intermittent explosive disorder •  Other neurodevelopmental disorders •  SLD •  IDD •  Reactive attachment disorder •  ASD •  Anxiety/Depression •  Bipolar •  Substance abuse disorders •  Psychotic disorders •  Personality disorders •  Medication induced symptoms •  Neurocognitive Disorders

*Red font indicates conditions more pertinent to adults

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Associated features • Mild delays in language, motor or social development

frequently co-occur • Associated features may include low frustration

tolerance, irritability, or unstable mood. • Academic or work performance is often impaired. •  Individuals with AD/HD may exhibit cognitive problems on

tests of attention, executive function, or memory, although these tests are not sufficiently sensitive or specific to serve as diagnostic indices.

• By early adulthood, AD/HD is associated with an increased risk of suicide attempts, primarily when comorbid with mood, conduct, or substance use disorders

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Additional Notes • Criteria provides examples, but this is not meant to limit to

other examples •  For adults (17+), lower the threshold for symptoms to 5.

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SPECIFIC LEARNING DISORDER

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Specific Learning Disorder • New overarching category of LD • Relating to learning and using skills in academic settings •  > 6 months impairment, despite intervention •  Impairment below developmental level • Begins or is noticed at school age • Specify

•  Reading •  Writing •  Math •  Process

• Severity For a summary of controversial issues see http://portal.idc.ac.il/He/Main/research/Documents/4_TANNOCK_Herzliya_DSM5.pdf

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Specific Learning Disorder Criteria A.  Difficulties learning and using academic skills, as indicated by the

presence of at least one of the following symptoms that have persisted for at least 6 months, despite the provision of interventions that target those difficulties:

1.  Inaccurate or slow and effortful word reading (e.g., reads single words aloud incorrectly or slowly and hesitantly, frequently guesses words, has difficulty sounding out words).

2.  Difficulty understanding the meaning of what is read (e.g., may read text accurately but not understand the sequence, relationships, inferences, or deeper meanings of what is read).

3.  Difficulties with spelling (e.g., may add, omit, or substitute vowels or consonants). 4.  Difficulties with written expression (e.g., makes multiple grammatical or

punctuation errors within sentences; employs poor paragraph organization; written expression of ideas lacks clarity).

5.  Difficulties mastering number sense, number facts, or calculation (e.g., has poor understanding of numbers, their magnitude, and relationships; counts on fingers to add single-digit numbers instead of recalling the math fact as peers do; gets lost in the midst of arithmetic computation and may switch procedures).

6.  Difficulties with mathematical reasoning (e.g., has severe difficulty applying mathematical concepts, facts, or procedures to solve quantitative problems).

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Specific Learning Disorder Criteria….cont. B.  The affected academic skills are substantially and quantifiably

below those expected for the individual’s chronological age, and cause significant interference with academic or occupational performance, or with activities of daily living, as confirmed by individually administered standardized achievement measures and comprehensive clinical assessment. •  For 17+ years, a documented history of impairing learning difficulties may be

substituted for the standardized assessment.

C.  The learning difficulties begin during school-age years but may not become fully manifest until the demands for those affected academic skills exceed the individual’s limited capacities •  as in timed tests, reading or writing lengthy complex reports for a tight deadline,

excessively heavy academic loads.

D.  Not better accounted for by intellectual disabilities, uncorrected visual or auditory acuity, other mental or neurological disorders, psychosocial adversity, lack of proficiency in the language of academic instruction, or inadequate educational instruction.

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SLD criteria: Important Notes •  The 4 criteria are to be met based on:

•  a clinical synthesis of the individual’s history (developmental, medical, family, educational), school reports, and psychoeducational assessment

Coding note: Specify all academic domains and subskills that are impaired. When more than one domain is impaired, each one should be coded individually according to the following specifiers (see next slide)

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SLD Specifiers q With impairment in reading:

q Word reading accuracy q Reading rate or fluency q Reading comprehension

q With impairment in written expression: q Spelling accuracy q Grammar and punctuation accuracy q Clarity or organization of written expression

q With impairment in mathematics: q Number sense q Memorization of arithmetic facts q Accurate or fluent calculation q Accurate math reasoning

• 

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SLD Severity Specifiers Specify Current Severity Mild: •  Some difficulties learning skills in one or two academic domains, but of mild enough

severity that the individual may be able to compensate or function well when provided with appropriate accommodations or support services, especially during the school years.

Moderate: •  Marked difficulties learning skills in one or more academic domains, so that the

individual is unlikely to become proficient without some intervals of intensive and specialized teaching during the school years. Some accommodations or supportive services at least part of the day at school, in the workplace, or at home may be needed to complete activities accurately and efficiently.

Severe: •  Severe difficulties learning skills, affecting several academic domains, so that the

individual is unlikely to learn those skills without ongoing intensive individualized and specialized teaching for most of the school years. Even with an array of appropriate accommodations or services at home, at school, or in the workplace, the individual may not be able to complete all activities efficiently.

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SLD: Associated Characteristics •  Frequently, but not always preceded by delays in

•  Attention •  Language •  Motor skills

• Uneven abilities are common • Varied cognitive deficits present • Specific learning disorder is associated with increased risk

for suicidal ideation and suicide attempts in children, adolescents, and adults

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Conditions to Consider with SLD Mental and Neurodevelopmental

Disorders

• AD/HD • DCD • ASD • Depression/anxiety • Bipolar disorder

Differential Dx

• Normal variation •  IDD • Neurological and sensory

disorders • AD/HD • Psychotic disorders

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Implications of changes •  Tests based on DSM IV will require updating • Sensitivity in younger children? • Move away from using DSM for research and tests? • Prevalence rates to decrease? • Service for children who would have met DSM IV, but

don’t meet DSM V (regardless of severity)? • Vocabulary changes should not deprive individuals of:

•  Identity •  Service •  Access to info

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2013-­‐10-­‐22  

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Helpful Resources •  http://www.dsm5.org/Pages/RecentUpdates.aspx •  http://www.autismspeaks.org/what-autism/diagnosis/

dsm-5-diagnostic-criteria • Get your Fact sheets Here: http://www.dsm5.org/Documents/Forms/AllItems.aspx

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Acknowledgements • Kind thanks to Dr. Jen Thule for reviewing and providing

feedback

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